A few months ago one of my docs had an idea: Let’s resurrect journal club. To some, the idea of hosting a “journal club” made little sense for a community, non-academic practice. In fact, some of our team, especially our physician assistants and nurse practitioners, had no idea what a journal club was. Others who remembered journal clubs of yore thought it could be a great opportunity to discuss up-to-date topics and have the opportunity to socialize with our colleagues in an off-campus, relaxed atmosphere.

Initially, I was skeptical. I remembered journal clubs from residency and never really liked them. For one, journal “clubs” were a misnomer, as they were never really club-like (By the end of residency, I could have had a PhD in clubbing and I knew journal clubs were very, very different). And two, the articles seemed so academic, esoteric and boring to a sleep-deprived, barely-holding-on-to-sanity resident. But now after being out of residency for 10 years and amassing a significant dose of maturity, I began to see the value in hosting such an event. So I decided: Let’s do it.

To my surprise, our first journal “club” attracted quite a number of participants. After socializing, we took our seats to go over the assigned articles. I picked five articles; three were medical articles and two were non-medicine articles on mustaches and implicit bias (And before you wonder if I made a typo, yes, I picked an article about mustaches. I have a mustache so I was drawn to the title). I wanted our journal clubs to be a little different, where we discussed not only up-to-date medical practice, but discussed “hot topics,” issues surrounding physician wellness, and diversity and inclusion.

After discussing the three medicine articles, we started in on men’s facial hair. The article, released in 2015 by researchers at the University of Pennsylvania, hypothesized that men with mustaches were in more leadership positions in academic medicine than women. As I began to present the mustache article, many of my team appeared annoyed and others shook their heads in frustration as I explained the study’s conclusions that men hold 87 percent of academic leadership positions. Further, despite the relatively rare facial hair fashion statement, more mustached men hold leadership positions (19 percent) than women (13 percent). Overall, academic medicine institutions had a “mustache index” of 0.72 (13/19).

After presenting the article and discussing some of the initial points, I asked an open-ended question: Why do you believe fewer women are in leadership positions than men? All the women in the room began looking around at each other as if they were all in on some sort of inside joke that I had missed out on. So I asked again. Then there was a collective sigh. Some of the responses of my mostly female group were as I expected. A few discussed the challenges women have with juggling leadership and home duties. Administrative positions simply did not take priority when compared to caring for their children. Others were more pointed, conveying great frustration with misogyny in medicine going back all the way to medical school and residency.

“Men have more drive and ego,” one of my colleagues said. To which I countered, “Is that true? Do men really have more of an ego than women or did we as a society condition women and men to believe that it’s more acceptable for men to have a more assertive tone and more drive than women?” Some agreed. Society was partially to blame. Another said, “Dr. XYZ (one of our notorious inpatient attendings) always refers to me as ‘girl’ and is condescending to me on the phone.” Another, speaking about a previous practice experience, expressed the real anxiety she felt being the only female in an all-male practice. She went to work every day believing that she had to exceed the expectations and outperform male colleagues to be considered credible and equal. Now, being in a much more inclusive practice, she feels more at home.

What surprised me the most, however, was one of the final comments: “I’m just glad you were willing to talk about this. It says a lot.” (Everyone nodded in agreement.) Think about that for a minute. One of my staff members was just happy that I, a white male with a beard and mustache, acknowledged the gender issues (sexism and misogyny) and gender disparities in medicine. That acknowledgement, she believed, made her feel comfortable to speak to me about advancement opportunities or any other issue. For me, this comment was a “light bulb” moment and a huge win. Could simply talking about these issues open the door to other women or under-represented groups seeking leadership opportunities? Could broaching the subject matter of gender inequality promote greater inclusion in our practice? Quite possibly.

As a regional medical director for EmCare and Chief of EM at my two-ED campus, I am positioned to make real impacts on diversity and inclusion both in the people I hire and in the atmosphere of inclusion I promote. I’m proud to say that after two years as the leader of our practice, we are more diverse than ever (60 percent of our providers are female and 67 percent are non-white). Two of my medical directors are female and both advanced practice leaders are female. Furthermore, our practice truly reflects the community we serve—a community where more than 87 languages are spoken in the public school.

When I first took the leadership position at our hospital, I had one goal: Become the premier emergency medicine practice in the region, delivering the highest quality healthcare. While the idea is simple enough, executing on such a lofty goal is quite difficult. One area where I knew we needed to continue to improve was on practice diversity. Study after study indicates practice diversity not only benefits our patients, but also our employees and our business. With that in mind, I realized expanding diversity is not just a “nice-to-have;” it’s a necessity.

To ensure a healthy, happy workforce and practice, leaders must begin acknowledging the underrepresentation of women and minorities in our field. We must ensure we support an atmosphere of inclusivity and openness. So where do we being? Maybe hosting a journal club where we talk about and acknowledge the “mustache index” is a simple way to get the conversation started.

N. Adam Brown, MD, MBA, FACEP, is a board-certified practicing emergency physician and the system chief of emergency medicine at Sentara Northern Virginia and Sentara Lake Ridge emergency departments in Northern Virginia. He also serves as regional medical director for EmCare’s North Division, where he leads a team of EM providers, six medical directors, and an administrative support staff for hospitals in New Jersey, Virginia and North Carolina.

As hospital and health system CEOs continue to see their organizations’ bottom lines being squeezed by a confluence of factors – declining reimbursement, demand for enhanced value from patients and payers, heightened focus on improving the quality of care and the overall patient experience – they are turning to a variety of tactics. One of the leading strategies is outsourcing for physician resources.

While outsourcing isn’t a new phenomenon, it’s taken on increased importance, especially as a way of decreasing costs, strengthening alignment with physicians and supporting efforts to improve patient care and operational efficiencies. Physicians also are seeking shelter from the growing financial and regulatory pressures bombarding their private practices. They are turning to employment arrangements with healthcare organizations (HCOs) via outsourcing companies or direct contracts with hospitals and health systems, many of which are beginning to offer the support of outsourced management services.

HCOs first dipped their toes into the outsourcing pool by contracting out their support services including environmental services and food services. Clinical outsourcing began more than 40 years ago when emergency medicine became a medical specialty. Today, the top five most commonly outsourced patient care services include dialysis, anesthesia, diagnostic imaging, hospitalist staffing and emergency department staffing1. In 2012, some 35 percent of all outsourcing agreements fell into this category, and the trend has remained steady over the past few years2.

How the Changing Environment Is Impacting Outsourcing

There’s no doubt the whirlwind of change that is engulfing hospitals is pushing them to look outside of their own walls for relief. Hospitals are being driven by a near-desperate need to reduce operating costs to cope with lower reimbursement rates, so they are increasingly turning to outside contractors.

Contributing to the historic changes taking place in the healthcare environment is the changing face of the physician workforce. In 2014, the Physicians Foundation conducted the Survey of America’s Physicians: Practice Patterns and Perspectives. More than 20,000 physicians responded to the survey, which found that there is a crisis in private practice with a strong migration toward the hospital employment model. The survey showed that solo practice volume dropped from 24 percent in 2012 to 17 percent in 2014. It pointed out the following challenges remaining in private practice – the administrative burden; the lack of access to capital; and the need to have communication with other physicians, physician groups and hospitals through large, expensive electronic medical records (EMR) systems.

What’s In It for Hospitals That Choose to Outsource?

How can an HCO determine whether to outsource services or keep them in-house? The Healthcare Financial Management Association offers these key questions to ask before making a final decision:

What barriers has your hospital encountered to achieving your business objectives? Why is outsourcing likely to solve a problem?

What are the sources, anticipated financial benefits, and true costs of outsourcing the function? Will outsourcing provide access to lower-cost computer capabilities? Will it provide lower labor and benefits costs (and if so, how will that be accomplished)?

What impact will outsourcing have on hospital employees? Will outsourcing provide additional benefits, better leadership, or more training? Will the outsourcing decision be viewed as a positive step or one that has to be “sold” within the organization?

How will outsourcing improve patient service and satisfaction?

With hospitals typically being one of the largest employers in a community, how will outsourcing affect the broader community?

Not only are an increasing number of healthcare organizations choosing to outsource staffing or practice management services in clinical areas, many are now realizing the incremental value of seeking one outside partner for several service lines. There are many reasons for this trend, including reduced physician recruitment and retention costs, improved operational efficiencies, strengthened alignment between HCO and physicians, accelerated development of physician leadership and improved clinical quality and outcomes.

“A hospital may be stuck, for example, on how to improve management of pneumonia patients,” says Francisco Loya, MD, chief executive officer of EmCare Hospital Medicine. “A local group of physicians only has a local perspective of the market. We have the advantage of working with hundreds of hospitals and health systems across the country, so we can identify best practices at similar size organizations and share those with our hospital partner or local practice. Because of our structure, we can immediately implement practice changes and monitor performance for achieving the desired outcomes.”

Other benefits of outsourcing include:

Access to resources

Better hospital-physician alignment

Leadership development opportunities

Improved metrics

Continuity of care/integrated services

EmCare and our parent company, Envision Healthcare, are changing the face of healthcare by pioneering solutions that increase the quality and experience of care while simultaneously reducing costs. By marrying our leading hospital-based physician group with the largest EMS and medical transportation organization (AMR) and launching a cutting-edge mobile integrated healthcare organization focused on post-acute care and intervention (Evolution Health), we are positioned to be on the leading edge, driving solutions for the future-state of healthcare.

Hospitals continue to seek opportunities to work with strong partners to protect their bottom line. Outsourcing physician resources offers benefits to patients, physicians and HCOs. Outsourcing has become an important thread woven into America’s delivery of healthcare and will continue to help hospitals and health systems achieve sustainable improved performance.

It's National Doctors' Day! Envision physicians share their personal stories about why they became a doctor.

Dr. Michael LozanoEmergency Medicine

I grew up in a poor neighborhood in Brooklyn, and there were two factors in my childhood that drew me to medicine. When I was in third grade, I spent 74 days in the county hospital. Needless to say, I was around doctors and nurses a lot. It was a municipal teaching hospital, so there were about a dozen or so people who came around every day on rounds to check on me. I was impressed by one doctor, who seemed to have all of the answers – and all of the tough questions for the residents. I vividly remember thinking on the bus after being discharged that I wanted to be one of those people in the white starched coats whose days were occupied with taking care of people.

The second influence was the New York City EMS team. There wasn’t any primary care to speak of in my neighborhood, so folks would just forgo care until there was no other option. In a roundabout way, it was through observing these paramedics that I would eventually choose emergency medicine as my specialty, and why I always have a soft place in my heart for paramedics.

Dr. Shilpa Amin
Emergency Medicine

Like many first-generation Indian Americans, my parents had a vision for me to become a doctor. My mother was accepted to medical school in India but her father wouldn’t let her attend because he feared that no one from his village would want to marry a highly educated woman. She left India as an unmarried 19 year old (which was unheard of at that time) and attended college at Murray State University in Kentucky in the ‘60s. While I was growing up, she would tell me that she wished that one of her daughters would grow up to be a doctor so she could live vicariously through us. Luckily, science, curiosity and care-taking come naturally to me, and so I pursued my dream – and my mother’s dream – of becoming a physician.

I studied medicine at SUNY Downstate and learned so much from the underserved population in Brooklyn. It was in Brooklyn where I found my calling in emergency medicine. I was attracted to the specialty because I love the unpredictable nature of the each shift. I truly enjoy the flexibility that EM offers to working mothers.

I feel fortunate to have found a career in which I can continue to learn every day, care for a variety of patients, be a director in a very busy urban ED and be the “team mom” for my son’s baseball team. And my mom still calls me after my shifts and asks me about my most interesting case of the night.

Dr. Gina Puglisi
Hospital Medicine

My grandfather came from generations of Italian craftsmen and farmers. When he moved to America, he was determined to create a better life for my father and uncles. He built an egg farm, which my father inherited and turned into one of the largest egg packaging and distributing companies on the East Coast. My father had left school at grade 8 to work on the farm, working 18 to 20 hours a day. He told us kids that all he wanted was for us to go to college.

My mother came from a line of poor Irish immigrants. She finished high school and later decided to become a nurse. She worked a full-time job while attending nursing school full-time. She was an inspiration to me. As an ER nurse, my mother's stories about the ER made me want to go into medicine.

I practice today because I know that it took many generations of hard work in the fields, on the farms and in the kitchens to get me where I am today. I am grateful to all of my ancestors who dreamed of bigger and better things for their children and grandchildren. I honor them by being proud, persistent and dedicated.

Dr. Peter Q. Lee
Emergency Medicine

"Anyone can find sickness; the purpose of a physician is to find health.” – A.T. Still

I hope to find health in my patients by relating to them and trying to find the positives during their time of need. I hope to continue this not just in medicine but in my interactions with friends and family. I hope to be a light in every aspect of my life.

Dr. Nathan Goldfein
Hospital Medicine

Despite my parents being told that I would probably not make it in college, I did go and chose a career in mechanical engineering. However, at nearly 40, two life-changing experiences changed my mind.

The first was being in a situation where I wanted to help someone but couldn’t. I was on a flight when a passenger had a heart attack. I felt helpless because I didn’t know how to help him. It was an awful feeling. The second was a lingering regret from earlier in my life. In 1986, when I was designing and manufacturing air brake systems, NFL players went on strike. I was playing Texas League football. I wanted to try out for the Houston Oilers, but didn’t. I always regretted not trying and vowed not to ever let that happen again. The bottom line was that I was interested in medicine and didn’t want another opportunity to pass me by. Although I was sure I wouldn’t get into medical school, let alone finish, I didn’t want to fast-forward to my 70s, sitting in a rocking chair, filled with another regret about a chance I didn’t take because I was afraid of failure.

Looking back, I know that I’m a better physician because of my engineering background. My advice for those thinking about a career in medicine is simple: You’ll regret what you don’t do more than what you do. It’s always better to try and fail then play it safe and never take the risk.

Dr. Ed Eppler
Emergency Medicine

I’d like to say that medicine was a lifelong dream to serve others, but in realty I think it’s as simple as both of my parents worked in hospitals while I was growing up, and I followed in my their footsteps. I chose emergency medicine while rotating on a required family practice clerkship and admitting ER patients to our service. It was an instant love affair.

Dr. Eric Schuck
Emergency Medicine

I decided to become a doctor to serve others. I chose pediatric emergency medicine because I love caring for children and families. They are vital to our future!

Dr. Daniel Smith
Anesthesiology

Originally I wanted to become a surgeon, but after my intern year I found I really just liked being in the OR taking care of patients.

Dr. Cesar Aristeiguieta
Emergency Medicine

I was a police officer and EMT. I worked with EM residents at Kern Medical Center and became interested in becoming an emergency physician. I thought they were cool people and wanted to be “part of the club.”

Dr. Nicole Haig Jasper
Emergency Medicine

I decided to become a physician because I am a “people person” and I have an innate desire to see people happy and healthy.

I choose emergency medicine for several reasons. The great lifestyle, when my shift is over I leave work at work, as well as the intensity and the diversity. Emergency medicine is ever changing; it’s like a box of chocolates – never know what you are going to get. I can't really predict what my day is going to be like, which is a huge factor in what keeps me motivated to go back to the ED each day. I'm also a people person. I love meeting new people every day. I meet their family and friends, hear their stories and learn some of their most intimate details within moments. I love that interaction. But above all, I get immense personal satisfaction when I know I've made a positive difference in the lives of my patients.

Dr. Jeff Davidson
Emergency Medicine

I had many positive influences when I was younger that opened my thoughts to becoming a physician. My father practiced podiatry and was a great influence on both me and my sister, who practices anesthesia. I learned that the practice of medicine was a lifelong commitment of learning, training and practicing. I was drawn to the idea that you would continually need to challenge yourself to stay atop of practicing medicine. I knew that my personality and drive were ideally suited to becoming a physician and committing to taking care of others.

Dr. Ije Akunyili
Emergency Medicine

Medicine is a second career for me. I started off working in economic policy and development for the World Bank. I became a doctor because I felt like I couldn't change the trajectory of world poverty but I could help one patient at a time. I walked into the emergency department my first week in medical school and never looked back.

Dr. Brian Haas
Hospital Medicine

I decided to become a doctor after I was told that I had a heart condition during my senior year sports physical in high school. I was initially told I was not allowed to do anything strenuous, until more testing had been done. I remember being terrified and wishing that I understood more of what was going on. At that point I decided that I needed to become a doctor so that I could understand myself as well as to help others to be less afraid than I had been.

Dr. Kathryn Cullen
Hospital Medicine

I always wanted to help people and my mother was a nurse, so she sparked my interest in medicine as a way to do it.